BILL NUMBER: SB 168	CHAPTERED  09/29/00

	CHAPTER   845
	FILED WITH SECRETARY OF STATE   SEPTEMBER 29, 2000
	APPROVED BY GOVERNOR   SEPTEMBER 28, 2000
	PASSED THE SENATE   AUGUST 31, 2000
	PASSED THE ASSEMBLY   AUGUST 31, 2000
	AMENDED IN ASSEMBLY   AUGUST 30, 2000
	AMENDED IN ASSEMBLY   JUNE 6, 2000
	AMENDED IN ASSEMBLY   JULY 12, 1999
	AMENDED IN ASSEMBLY   JUNE 24, 1999
	AMENDED IN SENATE   APRIL 21, 1999

INTRODUCED BY   Senator Speier
   (Coauthors:  Senators Rainey, Solis, and Vasconcellos)
   (Coauthors:  Assembly Members Bock, Cunneen, Kuehl, Strom-Martin,
and Zettel)

                        JANUARY 11, 1999

   An act to add Section 1367.36 to the Health and Safety Code,
relating to health care service plans.


	LEGISLATIVE COUNSEL'S DIGEST


   SB 168, Speier.  Health care service plans:  immunizations for
children: reimbursement of physicians.
   Existing law provides for the licensing and regulation of health
care service plans by the Department of Managed Care.  Existing law
requires every health care service plan that covers hospital,
medical, or surgical expenses on a group basis to provide certain
preventative health care benefits for children, including
immunizations.  A willful violation of the provisions governing
health care service plans is a crime.
   This bill would generally prohibit a risk-based contract between a
health care service plan and a physician or physician group that is
issued, amended, delivered, or renewed in this state on or after
January 1, 2001, from including a provision that requires a physician
or a physician group to assume financial risk for the acquisition
costs of required immunizations for children as a condition of
accepting the risk-based contract.  This bill would provide that a
physician or physician group shall not be required to assume
financial risk for immunizations that are not part of the current
contract. This bill would require plans to reimburse physicians or
physician groups for immunizations that are not part of the current
contract at not less than a specified amount, until the contract is
renegotiated.  This bill would prohibit a health care service plan
from including the acquisition costs associated with required
immunizations for children in the capitation rate of a physician who
is individually capitated.  This bill would enact other related
provisions.  Because a willful violation of the bill's requirements
would be a crime, this bill would impose a state-mandated local
program by creating a new crime.
  The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:


  SECTION 1.  Section 1367.36 is added to the Health and Safety Code,
to read:
   1367.36.  (a) A risk-based contract between a health care service
plan and a physician or physician group that is issued, amended,
delivered, or renewed in this state on or after January 1, 2001,
shall not include a provision that requires a physician or a
physician group to assume financial risk for the acquisition costs of
required immunizations for children as a condition of accepting the
risk-based contract.  A physician or physician group shall not be
required to assume financial risk for immunizations that are not part
of the current contract.
   (b) Beginning January 1, 2001, with respect to immunizations for
children that are not part of the current contract between a health
care service plan and a physician or physician group, the health care
service plan shall reimburse a physician or physician group at the
lowest of the following, until the contract is renegotiated:  (1) the
physician's actual acquisition cost, (2) the "average wholesale
price" as published in the Drug Topics Red Book, or (3) the lowest
acquisition cost through sources made available to the physician by
the health care service plan.  Reimbursements shall be made within 45
days of receipt by the plan of documents from the physician
demonstrating that the immunizations were performed, consistent with
Section 1371 or through an alternative funding mechanism mutually
agreed to by the health care service plan and the physician or
physician group.  The alternative funding mechanism shall be based on
reimbursements consistent with this subdivision.
   (c) Physicians and physician groups may assume financial risk for
providing required immunizations, if the immunizations have
experiential data that has been negotiated and agreed upon by the
health care service plan and the physician risk-bearing organization.
  However, a health care service plan shall not require a physician
risk-bearing organization to accept financial risk or impose
additional risk on a physician risk-bearing organization in violation
of subdivision (a).
   (d) A health care service plan shall not include the acquisition
costs associated with required immunizations for children in the
capitation rate of a physician who is individually capitated.
  SEC. 2.  No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB of the California Constitution because the
only costs that may be incurred by a local agency or school district
will be incurred because this act creates a new crime or infraction,
eliminates a crime or infraction, or changes the penalty for a crime
or infraction, within the meaning of Section 17556 of the Government
Code, or changes the definition of a crime within the meaning of
Section 6 of Article XIIIB of the California Constitution.
